Complex challenges for EHR implementations

Top EHR Challenges in Light of the StimulusEnabling Effective Interdisciplinary, Intradisciplinary and Cross-Setting Communication

Journal of Healthcare Information Management, 24(1), 18-24

A recent article written by medical and healthcare professionals discussed the challenges of implementing an electronic health record system (EHR). Although the article discusses some interesting and valid points, I have additional comments, as presented below.

The article begins by discussing the fact that healthcare is a team activity, and the ability to improve care coordination among providers and clinicians represents a challenge to the concept of meaningful use. Authors report that "meaningful use will require additional sophistication in the way that clinical data is entered into the system and how it is used to support patient care."

Improving care coordination was one of the challenges mentioned in the article within the context of standards for collection of data. Authors state that data standards (e.g. SNOMED CT, CCD, and HL7) ignore the impact of the context of data and may have a negative effect on the validity and reliability of data captured at the point of care.

I take exception with this assertion, as the technical data standards used within an EHR are simply that — technical/software and data exchange standards.

Standards are an important and necessary part of the software puzzle if data sharing/transport is required to meet Meaningful Use criteria. It does not, and should not, have an impact on whether or not the data entered into the system is reliable or valid. Reliability and validity of data within an EHR is completely dependent on the manner in which the data is entered into the system. For example, if vital signs are not accurately entered into the system, resulting calculations for BMI will be neither accurate nor valid.

Cumbersome data entry was also mentioned as a challenge using an EHR. I agree that in order for an EHR system to be used appropriately by clinicians and providers, the ability to enter data into the system must be developed using intuitive design principles.

It is true that if the system is difficult to use, data difficult to retrieve, or not made available in a manner that supports clinician-to-clinician communication, decision-making and care, it will not be used effectively.

When I first was introduced to VistA, the VHA EHR system, I observed that the data appeared fragmented from a nurse’s perspective and that in order to gain an overall view of the patient’s important clinical data, a high degree of knowledge regarding HOW to use the system and WHERE to find the data was required.

That said, the ability to communicate among clinicians/providers, is not the primary function of an EHR. Electronic systems are the starting point for the collection of data, not the sole mechanism for coordination of care or decision making at the point of care. Coordination of care, in this light, is a function to exchange data and communicate with others who support the “team’s” goal for improving patient outcomes and care. Yes, EHRs have the ability to exchange data, and with the proposed standardized technical exchange formats, data exchange among providers, registries, facilities, etc. is made possible with recognized data definitions.

It might also be true that clinicians may view the data within an EHR as yet another requirement, rather than using that information to improve patient care and outcomes.

Missing or Invalid Data: Authors describe the “noise” of unfiltered data as a challenge for using an EHR. Since I personally believe that the data contained within a paper chart is analogous to the data contained within an electric chart, I don’t see the difference. It is true, that there may be additional information captured within an EHR, but the use of the data is a “mind-filtering” effort. An example of what might be considered noise to a provider are the alerts arising from drug interactions that may often be ignored or overwritten. Authors correctly state that “finding the signal within the noise can be a challenge due to the sheer volume and variety of data contained in the patient record.” A question that begs to be answered then is, How is this different than the volume of information within a paper chart?

“Noise” may also be characterized as “Alert fatigue” which is a behavior when an inundation of alerts appear that require a response. Now this is a unique aspect of an EHR...

The article correctly points out that,

Implementation of health IT solutions must recognize the pitfalls of information overload and find the balance between pushing critical and timely data in context with the ability to search and select data needed by a specific provider in a specific context.

What is meaningful, then, depends on a particular patient, the clinical use of what is being recorded and what personnel are recording it.

In conclusion, the authors recommend that the government mandate creation of standardized “meaningful Use” measures to improve coordination of care and address the complexity of migration from paper to electronic records.

Although this is an interesting viewpoint, I do not believe that “use” is something that can be mandated or standardized as there are a variety of medical specialties that use data in specific practice areas and in a manner that supports their medical specialty for delivering care to patients with specific health conditions. For example, a Pediatrician has different data requirements for clinical decision making than an Orthopedic Surgeon.

That said, the adoption of EHR systems should be performed in an incremental fashion for practices and facilities, taking special considerations for clinician education, documentation, practices, and protocol.

Provider/clinician education that defines HOW the information will be gathered and entered into the system, HOW and with WHOM the data will be shared, and HOW care coordination among the Healthcare team will occur, is as of yet, unmet answers to our complex healthcare delivery system.